A TALE OF A TRAVELING FLUKE

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Paragonimiasis causes a range of pulmonary symptoms. Paragonimiasis is common in Eastern/Southeastern Asia, but in the era of worldwide travel this diagnosis should be considered more routinely. CASE PRESENTATION: A 21-year-old man with a MLH1 gene mutation was noted to have a left pleural effusion on surveillance imaging in December 2018. He had onset of progressive chest pain and fatigue around February 2018, and earlier, in summer 2017, had traveled to Singapore, Indonesia, and Thailand, where he ate fresh water crab and swam in fresh water. Vital signs were normal. Lab studies were notable for 19% eosinophils on differential count. A pigtail catheter was placed. Fluid was yellow, with pH 7.53, LDH 3,325 (serum 167), glucose < 5, total protein 8.3 (serum 8.7), and cell count with 52% eosinophils, 2% neutrophils, 19% lymphocytes. Cultures, cytology and flow cytometry were negative. There was high suspicion for paragonimiasis given consumption of fresh water crab, travel, and pleural/peripheral eosinophilia. Computerized tomographic imaging showed a left-sided pneumothorax, trapped lung, loculated material in the pleural space, and a cystic lesion. He underwent thoracoscopic decortication and removal of the cystic lung lesion. Surgical pathology revealed chronic fibrous pleuritis and cystic lung lesion with necrotizing granulomatous inflammation. He received empiric treatment with praziquantel given severity of disease and anticipated delay in serologic results. DISCUSSION: Paragonimiasis, or lung fluke, is acquired by eating raw or undercooked crustaceans. It often presents as pulmonary disease but rarely can produce gastrointestinal, dermatologic, or neurologic manifestations. It can be asymptomatic or cause eosinophilic pleural effusion, pneumothorax, or hemoptysis. Disease is classified into early or late infection. Early infection (first 2 months) involves larvae migrating into the pleural cavity. Late infection causes inflammation/fibrosis of the pleural cavity. Peripheral and pleural eosinophilia are characteristic. Diagnosis is confirmed by serology or microscopy (eggs in sputum, lung lavage, or stool). Serology is most useful with isolated pleural disease or extrapulmonary disease. Treatment is with praziquantel 75 mg/kg/day for 3 days. Those with high disease burden or chronic infection may require retreatment. If disease is untreated, the initial manifestations are likely to recur. Our patient’s peripheral eosinophilia resolved after surgery and antihelminthic therapy. Paragonimiasis serology was positive. CONCLUSIONS: Paragonimiasis should be considered in those with a history of travel to endemic regions presenting with pulmonary processes. Praziquantel is effective and well-tolerated, but extensive pulmonary disease may require surgical intervention. Reference #1: DeFrain, M, Hooker, R. North American Paragonimiasis: Case Report of a Severe Clinical Infection. CHEST 2002; 121:1368-1372 Reference #2: Kim, Hyun Jo. Pneumothorax Induced by Pulmonary Paragonimiasis: Two Cases Report. Korean J Thorac Cardiovasc Surgery. 2014 Jun 47(3) 310-312. Reference #3: Centers for Disease Control and Prevention (CDC). Human paragonimiasis after eating raw or undercooked crayfish--Missouri, July 2006-September 2010. MMWR Morb Mortal Wkly Rep 2010; 59:1573. DISCLOSURES: No relevant relationships by Christine Nayar, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Consulting fee Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Consulting fee Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Consulting fee Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Consulting fee Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Consulting fee Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Travel Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Travel Removed 03/17/2019 by Daniel Sterman, source=Web Response No relevant relationships Added 03/17/2019 by Daniel Sterman, source=Web Response, value=Consulting fee Removed 03/17/2019 by Daniel Sterman, source=Web Response